U.S. Department of State REQUEST FOR AUTHENTICATIONS …

U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE

Name (Last, First, MI)

SECTION 1: CUSTOMER CONTACT INFORMATION Suffix/Prefix E-mail

Home Phone

Extension Cell Phone

Extension

Work Phone Country

Extension

Formal Mailing Address Line 1

Case Type (If Federal Agency Must Be Official Business)

Select

Specify

Line 2

City

State

ZIP Code

SECTION 2: COURIER/REPRESENTATIVE CONTACT INFORMATION Are you submitting/retrieving this request on behalf of another individual? Name (Last, First, MI)

Select

Company

Phone Number

Extension

Delivery Method Select

Tracking Number Shipping Address

Same address as above Country

Country

Total Number of Documents

SECTION 3: SHIPPING DETAILS (FOR MAILED IN REQUESTS ONLY) Specify

Shipping Address Line 1

Line 2

City

State

ZIP Code

SECTION 4: DOCUMENT INFORMATION (CONTINUED ON NEXT PAGE)

Number of Documents

Document Type

Document Label (Official Use Only)

Select

Select

Select

SECTION 5: PROJECTED COST

Estimated Cost

DS-4194 02-2012

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Name (Last, First, MI) Country

Suffix/Prefix E-mail

SECTION 4: ADDITIONAL DOCUMENTS (CONTINUED)

Number of Documents

Document Type

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

Select

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Select

Document Label (Official Use Only)

DS-4194

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U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE

INSTRUCTIONS PURPOSE Form DS-4194 is used by the U. S. Department of State for documents submitted by U.S. citizens and foreign nationals. The Authentications Office is responsible for signing and issuing certificates under the Seal of the U. S. Department of State for documents being submitted to foreign countries. INSTRUCTIONS Complete one copy of this form for yourself or your company to be submitted with your documents and payment. You must submit a new cover letter for each request. Failure to do so will result in your case being rejected and documents being returned.

WARNING Any false statement or concealment of a material fact may result in a delay or un-authenticated documentation. FORM DS-4194

SECTION 1: REQUESTOR'S CONTACT INFORMATION

Provide individual's full name or company's name (complete spelling). Indicate e-mail address; telephone number(s) home, work and/or cell.

If the document(s) were mailed or hand carried for a Federal Agency for Official Government business please indicate agency name, bureau and/or office acronyms. Provide formal mailing address (include street address, city or town, zip code, province or country).

SECTION 2: SUBMITTER'S CONTACT INFORMATION

If you are submitting/or retrieving a request on behalf of someone other than yourself or a company, please provide specific and detailed information. The full name of the individual's or company's name is required to properly search the database.

If you are retrieving document(s) your name must appear in section 2 of the intake form and State issued identification is required.

Provide individual's full name or company's name (complete spelling). Indicate e-mail address; telephone number(s) day time, evening or cell number.

SECTION 3: METHOD OF RETURN (MAIL-IN)

Indicate delivery method (type of mail service used to return the document). If this information is available, provide a tracking number and include all letters and numbers (i.e., DOS, USPS, FED/EX, UPS, DHL & Others). Indicate the complete address that the document (s) will be returned to for proper delivery.

It is imperative that the complete address is entered accurately! (i.e., street address, city, state, ZIP code & country). REVIEW INFORMATION FOR ACCURACY!

Please note: All documents submitted will be returned to one location.

SECTION 4: DOCUMENT INFORMATION

Indicate the country (or countries) of use, the number of documents, and the document type. (A maximum of 15 documents are allowed per customer/company person for walk-in services).

SECTION 5: METHOD OF PAYMENT

Please note: The authentication processing fee is $8.00 per document, not per page. This fee will be charged regardless of whether you receive an authentication certification or a correspondence letter. This change in policy will take effect on April 1, 2012. Please pay the total amount shown in the estimated cost field. (The exact amount is required.)

Allowable payment methods include U.S. Postal Money Orders, checks (personal, corporate, certified, cashiers, travelers) all payable to "U.S. Department of State."

Walk-in service only: In addition to the payment methods noted above; Credit Cards and Debit/Check Cards (VISA, MasterCard, American Express, Discover) are accepted.

DS-4194 02-2012

Instructions Page 1 of 1

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